The Patient With An Altered Mental Status October

The Patient With An Altered Mental Status October 2009 CE Advocate Condell Medical Center Objectives by Jeremy Lockwood FFPM Mundelein Fire Department Prepared by Sharon Hopkins, RN, BSN, EMT-P

Objectives n n n Upon successful completion of this module, the EMS provider will be able to: 1. Identify components evaluated in determining a patient’s mental status and orientation. 2. Define altered mental status. 3. Identify the possible causes of altered mental status. 4. Identify signs and symptoms of altered mental status. 5. Identify elderly considerations related to altered mental status.

Objectives cont’d n n n 6. Identify assessment procedures related to patients with altered mental status. 7. Describe how to obtain an accurate Glasgow Coma Scale assessment. 8. Describe the procedure to obtain a blood glucose determinant. 9. Identify the components of the Cincinnati Stroke Scale. 10. Identify the treatment of patients with altered mental status.

Objectives cont’d n n n 11. Describe methods of restraining the combative patient. 12. Identify the indications, contraindications, complications, and documentation when using the Quick. Trach airway device. 13. Given a scenario obtain the GCS. 14. Perform assessment of the Cincinnati Stroke Scale. 15. Given a manikin, demonstrate placement of the Quick. Trach airway Device.

Normal Mentation n n To identify abnormal mental status, need to understand what is normal We all practice a number of means and ways to identify the mental status n n n General appearance Orientation to person, place, and time AVPU

General Appearance n Can gain important information looking at the “big picture” n n Observe hygiene Observe clothing Observe overall appearance Observe verbal and nonverbal behavior Facial expressions n Tone of voice, volume, quality, speech pattern n Eye contact n n n Memory intact for recent and long-term events? Is the patient focused; paying attention?

Orientation to Person, Place, Time n n Can be insulting to a patient to ask pointedly “what’s your name? ” “who’s the president? ” Often helpful to state: n n “Since I don’t know your condition very well, I need to ask some very basic questions. ” Person – patient can state their name Place – patient can recognize they are at home, in a store, in an ambulance, at a hospital Time – patient can tell what year it is and time of year (by month or season)

AVPU n A – alert meaning the patient is awake n n V – responding to verbal stimuli only n n Any response including fluttering of eyelids is a positive response to calling the patient’s name or asking a command P – responding to “pain” n n n “A” is not meant to indicate orientation; just level of awakeness Could also indicate responding to tactile stimuli so do not always need to inflict a painful stimuli Any response including fluttering of eyelids or any body twitch is a positive response U – unresponsive n Patient is flaccid with no responses at all

Stimulating a Painful Response n Acceptable methods n n n Unacceptable methods n n Pressing on supraorbital ridge (bone below eyebrow) Trapezium squeeze – twisting muscle where neck and shoulder meet Rubbing sternum with knuckles Pressing on finger nail bed Any technique that would leave bruising Discouraged methods n Any stimuli that may cause movement of the c-spine by the patient pulling away from the stimuli

Altered Mental Status n n n Patient not awake, alert or oriented Patient not aware of their environment Patient not oriented to person, place, time Patient confused Patient unable to demonstrate an understanding of what is being said Most important is noting any change over the course of time in level of consciousness

Level of Consciousness n n One of the first indicators to change when the level of perfusion is diminishing is level of consciousness FYI – The blood pressure is one of the last indicators to change when the level of perfusion diminishes

Possible Cause of Altered Mental Status n n Many lists have been created Mnemonics have been created to trigger lists n n n AEIOU-TIPS SMASHED EMS should think outside the box and look for all potential causes n When you find one cause, keep looking in case there are more than one cause associated with the altered mental status

Thinking Outside The Box How many squares do you see?

Thinking Outside The Box 30 squares: n n 1 large 4 x 4 square 16 small 1 x 1 squares 4 – 3 x 3 squares in each corner 9 – 2 x 2 squares

Mnemonic - AEIOU-TIPS n n n n n A – alcohol E – endocrine, electrolytes, encephalopathy I – insulin O – opiates U – uremia T – trauma – head injury, blood loss (shock) I – intracranial, infection P – poisoning; psychiatric S – seizures; syncope

Mnemonic - SMASHED n n n n S – substrates, sepsis n Hyper/hypoglycemia, thiamine M- meningitis, mental illness (ie: psychosis) A – alcohol (intoxication/withdrawal) S – seizure, stimulants H- hyper/hypothyroidism, hyper/hypothermia, hypotension, hypoxia, hypercarbia E – electrolyte imbalance, encephalopathy D- drugs of any sort

A - Alcohol n n n Includes beer, wine, and spirits Alcohol is a psychoactive drug with depressant effects Decreases attention and slows reaction speed Short term effects: intoxication, dehydration, alcohol poisoning Long term effects: changes to metabolism in the liver and brain; possible addiction Binge drinking n Men- 5 or more drinks in a row n Women – 4 or more drinks in a row

A- Alcohol n Evaluate n n n Clarity of speech Ability to comprehend the conversation Gait Not all persons drinking alcohol have altered mental states Contact Medical Control if the patient with alcohol “on board” wants to sign a release

E - Endocrine n n n Endocrine system is an informational system much like the nervous system Chemical messengers, hormones, travel mainly via blood vessels to trigger responses Common conditions involving the endocrine system n n n Diabetes mellitus Thyroid disease Obesity

E - Electrolytes n n n Electrically conductive medium n Principally: sodium, potassium, calcium, magnesium, chloride Activates muscles and neurons Homeostasis of electrolytes regulated by hormones Generally kidneys flush out excess levels of electrolytes Electrolyte disturbance (ie: dehydration or overhydration) may lead to cardiac and neurological complications (ie: medical emergencies) n Dehydration: exercise, diaphoresis, diarrhea, vomiting, intoxication, starvation

E- Encephalopathy n n n A syndrome of brain dysfunction Brain function and/or structure is altered Causes n n n Brain infection, tumor, increased intracranial pressure, exposure to toxins, radiation, tumor, poor nutrition, hypoxia, decreased blood flow to the brain Hallmark – altered mental status Common signs and symptoms include loss of cognitive function and subtle personality changes n More signs and symptoms listed in the notes section

I - Insulin n n Diabetes mellitus n The brain is very dependant on a set level of glucose to function n If the glucose level falls, the brain cannot function normally n Rapid change in behavior, level of consciousness when the blood sugar level drops All persons with altered level of consciousness need to have their blood sugar level checked

O - Opiates n n n n Used for pleasure and pain relief Depresses body functions and reactions Taken in pill form, smoked, injected Single dose effect can last 3 – 6 hours Detection time lasts usually up to 2 days High physical and psychological dependence Develop physical symptoms, behavioral symptoms, health effects, increased pain tolerance

Examples of Opiates n n n n Codeine Darvocet Demerol Dilaudid Fentanyl Heroin Hydrocodone Lorcet n n n n n Lortab Methadone Morphine Percocet Percodan Oxycodone Oxycontin Ultram Vicodin

Signs and Symptoms - Opiates n n n n Constricted pupils Sweating Nausea/vomiting/diarrhea Needle marks Loss of appetite Slurred speech Slowed reflexes Depressed breathing n n n n n Depressed pulse rate Drowsiness Fatigue Mood swings Impaired coordination Depression Apathy Stupor Euphoria

U - Uremia n n n Urea and waste products not eliminated from the blood Accompanies kidney failure/renal failure Usually diagnosed when kidney function < 50% of normal Early symptoms: anorexia and lethargy Late symptoms: decreased mental acuity and coma

Causes of Uremia (besides kidney failure) n Increased production of urea in the liver n n Decreased elimination of urea n n n High protein diet; GI bleed; drugs; increased protein breakdown (surgery, infection, trauma, cancer) Decreased blood flow through the kidneys (ie: hypotension); urinary outflow obstruction Dehydration Chronic kidney infections (chronic pyelonephritis)

T - Trauma n n Head injury n Epidural bleed n Rapid bleeding with unresponsiveness often following a lucid interval n Subdural bleed n Slow bleeding with subtle changes n Intracerebral bleed n Ruptured blood vessel releases blood into brain tissue with resulting tissue edema Blood loss shock

I - Intracranial n Tumor n Symptoms/neurological deficits often point to the area of brain affected n Right sided brain insult affects left sided body function n Left sided brain insult affects right sided body function

Intracranial cont’d n Head injury n Pupillary changes reflect same side of brain insult n Right pupillary change reflects right sided brain insult n Left pupillary change reflects left sided brain insult n Consider acute vs chronic condition n Chronic conditions: n Elderly with frequent falls n Chronic alcoholism with frequent falls

I - Infection n Meningitis n n n Urinary tract infection (UTI) n n Elderly often do not present with high fevers Sepsis n n Bacterial is highly contagious Mask the patient and all EMS personnel Newborns/very young infants will be very ill Encephalitis Pneumonia – viral and bacterial Liver abscess

P - Poisoning n n Drug overdose n Intentional n Assume you are not getting the full story n Mixing any meds with alcohol increases the risk of worsening conditions n Accidental n Assume young children will not be truthful (fear of being punished) Bring in all containers

P - Psychiatric n Schizophrenia n n Common mental health problem Hallmark – significant change in behavior and loss of contact with reality Hallucinations, delusions, depression Bipolar n n Not particularly common mental health problem One or more manic episodes with or without subsequent or alternating periods of depression

S - Seizure n n Epilepsy Head injury Hypoglycemia Hypertensive crisis n n Rapid increase in diastolic B/P >130 mm. Hg Hypertensive disorder of pregnancy n Formerly referred to as toxemia

S- Syncope n n Brief loss of consciousness with spontaneous recovery “Fainting” Typically a very short episode resolved when the patient lies flat (as in when they pass out) Often warning signs &/or symptoms n n Lightheadedness Dizziness Nausea Weakness Vision changes Sudden pallor Sweating

Causes of Syncope n n Hypovolemia – fluid &/or blood loss Metabolic – alteration in brain chemistry n n n Environmental n n n Hypoglycemia Inner/ middle ear problem Room temperature, carbon monoxide Toxicological – excessive alcohol Cardiovascular - dysrhythmias

Elderly Considerations n Contributing factors to confusion n n Stress Fear of removal from their home Talking with strangers (ie: EMS) Answering questions they do not know the answers to

Elderly Considerations n Altered mental status possibly due to: n n n n n Medical insult or traumatic head injury Heart rhythm disturbance; AMI Dementia Infection Related to prescription medications Decreased blood volume – shock Respiratory disorders and/or hypoxia Hypo/hyperthermia Decreased blood sugar level

Distinguishing Dementia From Delirium n Dementia n Chronic, slow progression n Irreversible disorder n n n Impaired memory Global cognitive deficits Most commonly caused by Alzheimer’s Does not require immediate treatment Delirium n Rapid in onset (hours to days), fluctuating course n May be reversed esp if treated early n Greatly impairs attention n Focal cognitive deficits n Most commonly caused by systemic disease, drug toxicity, or metabolic changes n Requires immediate treatment

Dementia n Causes of this progressive disorientation n n n Small strokes Atherosclerosis Age related neurological changes Neurological changes Certain hereditary diseases (ie: Huntington’s) Alzheimer’s disease

Delirium n n Disorganized thinking with reduced ability to maintain attention and to shift attention Synonyms: Acute confusional state ü Acute cognitive impairment ü Acute encephalopathy ü Acute altered mental status ü

Patient Assessment n ABC’s n Is ventilation/breathing adequate? n Does supplemental oxygen need to be given? n Room air contains 21 % O 2 n Nasal cannula delivers 24% - 44% O 2 (2 – 6 L/min) n Non-rebreather can deliver up to 100% O 2 (12 -15 L/min) n Does the C-spine need to be controlled? n Can the patient protect their own airway?

Patient Assessment n Adequacy of circulation n n What is the blood pressure? Does the blood pressure equate with the patient assessment? Is there a peripheral pulse? What is the peripheral pulse rate and quality? Do you need to gain IV access? n n Is IV access necessary? Is IV access needed as a precaution?

Patient Assessment n n n Cardiac monitor n Is there a dysrhythmia present? What is the blood sugar level? Does the patient require isolation for potential infectious disease? History n From the patient, caregiver, bystander History of present illness Pertinent past medical history

Patient Assessment n n Allergies Current medications Use of drugs or other substances Physical exam n Vital signs – B/P – R – Sp. O 2 n Hands-on assessment head to toe n Skin exam n Rashes? Evidence of infection?

Patient Assessment - Neurological n n Evaluate appearance, behavior, attitude Thought disorders – logical and realistic? n n n n False beliefs/delusions? Suicidal/homicidal thoughts? Perception disorders? Hallucinations present? Mood and affect Insight and judgement – can patient understand circumstances and identify surroundings? Sensorium and intelligence – normal level of consciousness? Impaired cognition/intellectual functioning?

Neurological Assessment cont’d n Level of consciousness n n AVPU Pupillary response Ability to identify person, place, time Glasgow coma scale n n Scores 3 – 15 More important than any one score is the trend the score is making

Glasgow Coma Scale n n Evaluates wakefulness and awareness Wakefulness n n The state of being aware of the environment Awareness n A demonstrated understanding of what is being said

GCS Tips n Always give the patient the best score possible n n n If the patient can move the right extremity and not the left, score for the movement of the right extremity Deteriorations will be noted faster as the score drops by awarding the highest points possible Pediatric component n Used for the young patient who is not verbal yet due to age

Glasgow Coma Scale EYE OPENING n VERBAL RESPONSE MOTOR RESPONSE 4 --Spontaneous 5 --Oriented 6 --Obeys 3—Verbal stimuli 5 --Localizes 2 --Pain 1 --None 4 --Confused/ disoriented 3 --Inappropriate 4 --Withdraws words 2 --Incomprehensible 3 --Abnormal flexion sounds 1 --None 2 --Extensor posturing 1 --None

GCS Score n GCS 13 – 15 n n GCS 9 – 12 n n Mild brain injury Moderate brain injury GCS <8 n n n Severe brain injury Most patients with this score are in coma Evaluate for the need to assist in protecting the patient’s airway

Evaluating Eye Opening n Best response is obtained, if at all possible, before physical contact is made with patient n n n This is not always possible when the C-spine needs to be controlled Patient gets credit if eyelids open even for a brief moment or just flicker Always consider need to control the C-spine over the verbal response of the GCS

Evaluating Verbal Response n n n 5 – uses appropriate words/conversation 4 – speaks but is confused and disoriented 3 – speaking and you can understand the words spoken but the words have no bearing on the current situation 2 – making sounds like grunts; no intelligible words 1 – no response; no speech; no noise

Modifying GCS for Pediatrics n n n Adult GCS must be modified to match the developmental age of the young nonverbal child Best eye opening remains unchanged Best verbal response for non-verbal patient n n n 5 – Smiles, coos, follows objects 4 – Irritable cry but is consolable 3 – Inappropriate crying; cries to pain 2 – Inconsolable, agitated; moans or groans to pain 1 – No response

Evaluating Motor Response n n 6 – Obeys commands 5 – Purposeful movement n n Hits at you, grabs at your hands, pulling equipment off, pushing you away 4 – Withdraws from pain (unable to localize) 3 – Flexing with internal rotation and adduction of shoulders and flexion of elbows 2 – Extension with elbows straightened and possible internal shoulder and wrist rotation

Pediatric GCS Motor Response n Best motor response for non-verbal patient n n n 6 – obeys commands n May be difficult to determine if child understands 5 – localizes pain by withdrawing to touch stimuli 4 – withdraws to pain (more stimuli than touch) 3 – same – abnormal flexion 2 – same – abnormal extension 1 – no motor response; patient flaccid

GCS Practice n Patient #1 n n The patient is watching you approach The patient speaks normally and answers questions The patient raises their arm when you ask to take their B/P Patient #2 n n n The patient is looking around the environment The patient speaks normally but is confused When you ask the patient to raise their arm, they are slow to do so but eventually raises their arm

GCS Practice n Patient #3 n n The patient’s eyes are closed and there is no movement even after squeezing the trapezius The patient groans when the trapezius is squeezed The patient flexes their arms to the chest wall Patient #4 n n n Patient eyes open briefly when their name is called Patient groans while being pinched Patient does not follow commands and pushes you away whenever you try to treat the patient

GCS Practice n Patient #5 n n Eyes are closed but open when calling the patient The patient yells “don’t” and “stop it” when being touched, assessed, and treated but is not speaking Patient pushes the EMS provider hands away and is trying to pull off the cervical collar and IV Patient #6 n n n Eyes open briefly when asked to open them The patient moans weakly when being touched The patient tries to pull away when care is being provided (ie: IV start)

GCS Practice n Patient #7 n n Patient refused to open eyes due to pain and squeezes them tighter when asked to open eyes The patient responds verbally saying their head hurts and the lights make it hurt worse Patient follows commands except for opening eyes Patient #8 n n n Eyes are open looking straight ahead When asked what month it is, the patient responds “he, umm, he, my jacket, don’t…” Does not follow commands. Pulls one hand away and the other hand is pushing the EMS provider away

GCS Practice – Pediatrics < 1 y/o n Patient #9 (6 month old) n n Infant’s eyes flutter when touched Patient cries when gently touched; is consolable Patient withdraws when first touching them Patient #10 (9 month old) n n n Eyelids flutter when the IO needle is placed Patient moans during the IO insertion and when deformed extremity is handled The patient pulls their arms into their chest wall rolling their shoulders and wrists inward

GCS Answers n n n n n Patient # 1 - 4, 5, 6 = 15 Patient # 2 – 4, 4, 6 = 14 Patient # 3 – 1, 2, 3 = 6 Patient # 4 – 3, 2, 5 = 10 Patient # 5 – 3, 3, 5 = 11 Patient # 6 – 3, 2, 4 = 9 Patient # 7 – 3, 5, 6 = 14 Patient # 8 – 4, 3, 5 = 12 Patient # 9 – 2, 4, 5 = 11 Patient # 10 – 2, 2, 3 = 7

Blood Glucose Level n n n To be obtained when: ü Patient is known diabetic with diabetic related problem ü Patient has an altered level of consciousness for unknown reasons ü Patient is unresponsive (includes post-ictal patients) Consider the patient to have more than one problem at a time n Make sure a 2 nd or 3 rd issue is not present once you find the first issue (ie: hypoglycemia) Be aware: Peds patients can drop their blood sugar level fast

Blood Glucose Monitor n n n Machines calibrated for capillary specimen Keep the site hanging dependently n Can use side of finger tips or the forearm Once the site is wiped with an alcohol prep pad, let the site air dry before obtaining a sample Use a lancet to obtain a blood sample from the finger or forearm Do not let a patient sign a release until you can document a blood sugar level >60

Stroke Care n n n Rapid detection of signs and symptoms with rapid diagnosis is essential Need to avoid delays n 3 hour time limit to administer a fibrinolytic from time of first onset of signs and symptoms n Increase risk of cerebral bleeding beyond a 3 hour time frame Most important question to ask: n What time did symptoms begin?

Cincinnati Stroke Scale n n Quick and simple evaluation tool Documentation n Facial droop n Right/left facial droop or no droop Arm drift n Right/left arm drift or no drift Speech n Clear or not clear

Facial Drooping n Ask the patient to smile real big and show you their teeth n Best way to see if a droop is present

Arm Drift n Demonstrate first and then have patient hold their hands out in front, palms up, for 10 seconds

Clarity of Speech n n Most likely you’ll know by now if there is a speech problem Can have the patient repeat after you any words or a sentence you give them n “You can’t teach an old dog new tricks”

7 D’S Of Stroke Care n n n n Detection – of signs and symptoms Dispatch – call 911 Delivery – to the appropriate facility Door – emergent triage in the ED Data – appropriate tests Decision – to administer a fibrinolytic or not Drug – must administer the fibrinolytic within 3 hours of onset of symptoms

Quick Fixes of Altered Mental Status n n n Hypoglycemia – Dextrose Hypoxia – oxygen Pinpoint pupils – Narcan Seizures – Valium n Dextrose if seizure due to hypoglycemia Cold – warm the patient up

Combative Patient n n n n Talking down a patient is an art that requires effort and skill Need enhanced people skills of listening and observation Make sure the scene is safe Provide a calm and supportive environment Treat any existing medical conditions Do not confront or argue with the patient Provide realistic reassurance Respond to the patient in a direct, simple manner

2 Extremes of Behavioral Emergencies n Combative patient ü Fidgeting, nervous energy ü Voice getting louder ü Pacing ü Shouting, apparent anger n Withdrawn patient ü Facing away from EMS ü Decreasing eye contact ü No eye contact or conversation ü Totally withdrawn

System Operating Guidelines – Use of Restraints n EMS personnel should contact Medical Control if possible before restraining patient n n n May restrain patient first for patient and personnel safety All attempts must be made to avoid injury to patient and EMS personnel Do not compromise the patient’s ability to breath or further aggravate any injury or illness Clearly document the behavior leading to use of restraints Handcuffs applied by police only n Officer must accompany patient in the ambulance during transport

Methods of Restraint n Verbal de-escalation n First method to employ Avoids physical contact with the patient – safer Watch “personal space” n n 1. 5 – 4 feet in the United States Keep open an “escape route” for yourself

Methods of Restraint cont’d n Physical restraint n n n Materials or techniques that will restrict the movement of a patient Soft restraints: sheets, wristlets, chest Posy Hard restraints: plastic ties, handcuffs, leathers n Police must be in ambulance for transport if patient is in handcuffs Patients need frequent reassessment to evaluate for injury or possible neurovascular compromise or airway compromise Use a surgical mask placed loosely over the face to control spitting

Physical Restraints n Do not transport a restrained patient prone n n n Positional asphyxia may cause death Be prepared to protect the patient’s airway Do not secure straps to moving side rails Restraining thighs just above knees often prevents kicking Struggling against restraints may lead to severe acidosis and fatal dysrhythmias NEVER leave restrained patient unattended

Methods of Restraints cont’d n Chemical restraint n n Administration of specific pharmacological agents n Decrease agitation n Increase cooperation n Not alter a patient’s level of consciousness Common agents used are haldol (in the ED) and/or benzodiazepines n Diazepam (Valium) n Lorazepam (Ativan) n Midazolam (Versed)

SOP - Severe Anxiety or Agitation n Valium 5 mg IVP slowly over 2 minutes n n Repeat as needed Maximum total dose is 10 mg In the absence of an IV, Valium 10 mg IM/rectally Watch for respiratory depression with administration of a benzodiazepine n Have a BVM ready to use as a precaution

Documentation Tips n n All patients require a blood glucose level for altered mental status Documentation should reflect serial monitoring of the patient’s condition looking for changes n n GCS AVPU If restraints are used, document objectively and in detail the behavior that led to the need for restraints n Document distal circulation of any restrained extremity Patients with altered mental status cannot sign a release

Securing the Airway - Quick. Trach n Indications n n n Patient requires emergency assisted ventilation when all other conventional methods have failed Contraindications n Tracheal transection n Other less invasive maneuver allows ventilation >77# (35 kg) – use 4. 0 mm ID device 22# – 77# (10 -35 kg) use 2. 0 mm ID <22# (10 kg) – use needle cricothyrotomy

Quick. Trach Device Connecting tube Syringe Flanges to attach ties Stopper that is removed before final insertion

Quick. Trach Procedure n n Position patient supine; hyperextend neck if no trauma) Locate cricothyroid membrane and cleanse site n n n Palpate the soft indentation between the thyroid and cricothyroid cartilages Secure the larynx laterally between the thumb and forefinger Puncture the cricothyroid membrane at a 900 angle

Cricothyroid Membrane Target area

Quick. Trach cont’d n n n Confirm entry into the trachea by aspirating air thru the syringe n If air is present, the needle is in the trachea Now change the angle to 600 with the tip pointing towards the feet and advance the device forward into the trachea to the level of the stopper n Stopper to be snug against the skin n Stopper reduces risk of inserting the needle too deeply Remove the stopper

Quick. Trach cont’d n n n Holding needle and syringe firmly, slide only the plastic cannula into the trachea n Stop when the flange rests snug against the neck Carefully remove the needle and syringe Apply the connecting tube to the cannula Attach a BVM to the connecting tube n Begin to bag the patient Secure the cannula with the neck tape ties provided

Quick. Trach Complications n Puncture through of the trachea n n Inadvertent puncture of a blood vessel n n n During bagging attempts surrounding tissue will expand due to leakage of air Formation of a hematoma under the skin and surrounding the airway External bleeding Inability to ventilate the patient n There may be an obstruction at a more distal site

Quick. Trach Documentation n n Indicate the reason(s) an alternate airway devise was necessary Document size airway placed n n n 4. 0 mm for persons over 77# 2. 0 mm for persons 22# - 77# Document confirmation of airway placement n n Bilateral breath sounds Bilateral chest wall rise and fall

Case Study #1 n n 57 year old patient found behind a garage unresponsive. Breathing and has a radial pulse. Dry blood on lips. What are your impressions? How does your assessment proceed?

Case Study #1 n Impression list n n n n Post-ictal from seizure Hypoglycemia Alcohol intoxication Drug overdose Acute MI Stroke Head trauma

Case Study #1 n Assessment n n n Control c-spine while palpating neck area Evaluate if respiratory assistance is needed n Check quality, depth, rate of respirations, Sp. O 2 Calculate GCS; obtain vital signs Consider IV-O 2 -monitor n Assess for need for fluid challenge n Assess cardiac rhythm; consider obtaining a 12 lead EKG Obtain a blood glucose sample

Case Study #2 n n Patient’s spouse called EMS Patient dropping silverware at lunch, unable to sit up straight, unable to complete sentences Vital signs: 170/110; P – 64; R – 16; GCS -14 EKG monitor -

Case Study #2 n n What is your impression? What is the cardiac rhythm? n n n Atrial fibrillation How does this rhythm relate to any impressions? What assessments need to be done? n n Blood sugar level for all patients with altered level of consciousness Cincinnati stroke scale

Case Study #2 n Cincinnati stroke scale n n n Ask the patient to smile real big showing you their teeth Ask the patient to put their hands out in front, palms up, and close their eyes n Hold the position for 10 seconds Ask the patient to repeat a saying n “You can’t teach an old dog new tricks”

Case Study #2 n What’s the most important question to ask the patient? n When did the symptoms begin?

Case Study #3 n n n Your 18 year-old patient is found under the bleachers at school unresponsive with shallow respirations. AVPU - responds to painful stimuli Vital signs: 110/70; P – 110; R – 4; pupils constricted GCS – 8 What are your impressions?

Case Study #3 n Impression list n Drug overdose n n Opiates – constricted pupils, depressed respirations Head injury Hypoglycemia Post-ictal

Case Study #3 n Treatment n n Control c-spine n Consider c-spine injury until proven otherwise Secure airway n Frequency to ventilate? n Once every 5 – 6 seconds Gain IV access n Peripheral site? n IO if peripheral unobtainable Evaluate cardiac rhythm

Case Study #3 n Medications to administer n If blood sugar < 60 give 50 ml of 50% Dextrose n As a diagnostic tool give Narcan 2 mg IVP every 5 minutes as needed for desired effect n Maximum total of 10 mg n n Consider need to protect the airway with intubation following conscious sedation n No indication for lidocaine n Versed to relax the patient n Morphine alternated with Versed to potentiate the effects of both medications n Benzocaine if a blink reflex is present

Case Study #4 n n n You are called to the scene for an unknown medical emergency Police have secured the scene Your patient is a 54 year-old male who is combative What are your impressions? What actions are indicated?

Case Study #4 n Impressions n Psychiatric problem n Altered blood sugar n Head injury n Electrolyte imbalance

Case Study #4 n Action to take n n Make sure the scene is safe and remains safe for the rescuers 1 st and then the patient Will need a blood sugar at some point A cardiac monitor to evaluate rhythm could be important assessment information May need to restrain the patient for crew safety and patient safety

Case Study #4 n Methods to restrain patients Verbal de-escalation n Soft restraints n Wrist and ankle restraints n Chest posey or sheet n Hard restraints n If police handcuff the patient, police must ride with the patient in the ambulance n Police are not allowed to hand off cuff keys to EMS n

Case Study #4 n Documentation n Patient’s behavior in descriptive, objective terms that indicated the need for restraint If no time to contact Medical Control before restraining patient, contact them after the patient is restrained Document distal circulation, motion, and sensation periodically after restraining the patient

Case Study #5 n n n 32 year-old patient who was found combative at work. This is very unusual behavior for this patient Vital signs: 110/70; P – 80; R – 18; skin damp Impression? Further assessment? Treatment?

Case Study #5 n Impression n n Hypoglycemia Head injury Drug / alcohol influence Assessment n n n Blood sugar level Cardiac monitor Neurological evaluation

Case Study #5 n Blood sugar was 25 n Treatment indicated n n 50 ml 50% Dextrose IVP Patient now alert and oriented Repeat blood sugar 56 Patient wants to sign a release. Can they? n n No release until the blood sugar is >60 Stay on the scene and continue to reassess as the patient takes in food or liquids

Bibliography n n n n Bledsoe, B. , Porter, R. , Cherry, R. Paramedic Care Principles and Practices 3 rd Edition. Prentice Hall. 2009 Limmer, D. O’Keefe, M. Emergency Care. 10 th Edition. Prentice Hall. 2005. Region X SOP’s March 2007. Amended January 1, 2008. En. wikipedia. org/wiki/Endocrine_system En. wikipedia. org/wiki/Electrolyte_system En. wikipedia. org/wiki/Encephalopathy_system En. wikipedia. org/wiki/Opiate_system En. wikipedia. org/wiki/Uremia_system

Bibliography cont’d n n n n www. chems. alaska. gov/EMS/documents/GCS_Activity_ 2003. pdf www. doi. gov/nbc/eps/signsymptoms. html www. en. wikibooks. org. wiki/Emergency_Medicine/altered _mental_status www. nursingtimes. net www. opiates. com/opiates staff. washington. edu/momus/PB/comachan. htm www. ucsfcme. com/2008/slides/MDM 08 Q 05/01 sporer. pdf www. uic. edu/com/ferne/slides/Delerium. pps